Plantar Plate Injuries
Top Contributors - Ewa Jaraczewska and Jess Bell
Introduction[edit | edit source]
The plantar plate complex is essential for foot mechanics. It comprises the plantar aspect of the first metatarsophalangeal joint (MTPJ). It provides dynamic and static joint stability while protecting the joint's articular surfaces. The lesser toe plantar plates also provide joint stability and articular surface protection. When discussing plantar plate pathologies, clinicians must recognise two categories of injuries: MTPJ (great toe) and second through fifth (lesser toe) injuries.
Clinically Relevant Anatomy[edit | edit source]
The plantar plate complex has a thick, distal attachment at the base of the proximal phalanges of the feet. The thin proximal attachment extends to the metatarsal head-neck junction or to the intersesamoid ligament. It is inseparable from the plantar capsule, ligaments, and musculotendinous structures. It provides a cushioning system for the metatarsal heads and prevents them from dropping. The plantar plates of the lesser toes are a single dominant fibrocartilaginous capsular thickening and extend from the metatarsal head to the proximal phalanx base at each joint.
The plantar plate complex is a fibrocartilaginous pad that consists of three parts: bony, ligamentous, and musculotendinous.
The bony part includes:
The ligamentous part is comprised of:
- Sesamoid phalangeal ligaments (SPLs): these are the thickest ligaments of the first metatarsophalangeal joint (MTPJ). They prevent proximal sesamoid subluxation during hyperextension while walking or running.
- Intersesamoid ligament (ISL): transverse bundles of collagen fibres connecting two sesamoids bones.
- Paired metatarsosesamoid ligaments (MTSLs): are called suspensory ligaments. Their role is to assist with sesamoid stabilisation.
The musculotendinous part consists of the following:
- Medial and lateral heads of the flexor hallucis brevis which have a proximal attachment to the proximal and plantar surfaces of the medial and lateral sesamoids.
- Flexor hallucis longus which has an insertion at the base of the distal phalanx.
- Adductor hallucis which has its the main insertion at the sesamoids.
- Abductor hallucis which inserts at the sesamoids.
Plantar plate complex supportive structures:
- Medial and lateral metatarsophalangeal ligaments (collateral ligaments):
- These are not part of the plantar plate complex.
- They act as static stabilisers when valgus or varus forces are applied.
- Extensor hallucis longus (EHL) and extensor hallucis brevis (EHB):
- These are dynamic stabilisers during plantar flexion.
- Plantar fascia
- The plantar plate is attached to the central component of plantar aponeurosis and may be considered a distal extension of the plantar fascia.
The plantar plate receives its blood supply from the vascular network of the surrounding soft tissue; however, the mid portion of the plantar plate lacks sufficient vascularity.
Mechanism of Injury / Pathological Process[edit | edit source]
The first MTPJ plantar plate complex can be injured after an acute trauma or a chronic, degenerative process can occur.
- Acute trauma
- Osteochondral injuries of the sesamoids:
- Sesamoiditis: a painful, inflammatory condition in the acute phase, with sclerosis in the chronic phase
- Sesamoid fractures
- Osteonecrosis diastasis of a bipartite sesamoid
- Chondral injuries with loose osteochondral fragments
- Joint hyperextension causes injury to the sesamoid phalangeal ligaments
- Turf toe is an injury of the first metatarsophalangeal (MTP) articulation. It occurs during hyperextension of the MTP joint, with fixed equinus at the ankle. When unrecognised, it can become a debilitating condition with persistent pain, progressive deformity and joint degeneration. You can read more about Turf toe here.
- Articular surface injuries of the proximal phalanx and metatarsal head
- Caused by increased load on the metatarsal heads in the extended position of the metatarsophalangeal joint
- Jumping down from a height
- Injuries in dancers or sprinters (i.e. athletes who do a lot of work on their forefoot)
- Osteochondral injuries of the sesamoids:
- Degenerative process
- Other foot pathologies which overload the MTPJ and cause plantar plate injuries include:
- Excessive pronation
- Short first metatarsal
- Long second metatarsal
The most common injuries of the plantar plates of the lesser toes include the second and third MTPJ plantar plates. The pathologies are:
- Degeneration (thickening of the plate)
- Partial thickness tearing
- Complete tearing (defect at the plate insertion)
Clinical Presentation[edit | edit source]
The following signs and symptoms can indicate plantar plate injuries:
- The onset of persistent, constant, activity-related pain and tenderness over the metatarsal head (ball of the foot).
- Swelling under the ball of the foot that extends towards the toes.
- Symptoms similar to compression syndromes of the plantar digital nerves, as a result of micro trauma or a space occupying lesion. Symptoms include tenderness of the heel and medial plantar arch and numbness along the medial plantar foot.
- Widening of the interdigital space: The toe gapping sign (Churchill sign) - i.e. there is a greater spread between the 2nd and 3rd toe.
- Loss of ground touch: incapacity of the toes to touch the ground normally.
- Presence of minor toe deformities: dorsal elevation, crossover toe, pronation or supination.
Diagnostic Procedures[edit | edit source]
To confirm plantar plate injuries, the following diagnostic procedures are recommended:
- X-ray: completed in standing to visualise dropped metatarsals.
- Ultrasound: considered a first-line tool to quickly and accurately localise and characterise forefoot pathologies. Using static and dynamic ultrasound techniques is common for assessing plantar plate pathology, with dynamic assessment offering greater sensitivity. A partial- or full-thickness plantar plate defect is the most common presentation of a plantar plate tear that can be easily detected on ultrasound.
- Computerised tomography (CT) can be used in challenging situations where surgery is required for plantar plate injury. This is a diagnostic procedure of choice when signs and symptoms of soft tissue injury are present.
- Magnetic resonance imaging (MRI) has high accuracy in diagnosing plantar plate injuries. It is a preferred procedure to differentiate between plantar plate injury and Morton's neuroma.
Assessment[edit | edit source]
Interview[edit | edit source]
Taking a patient's history is an excellent point of reference. The patient should be asked about the following:
- Predisposing factors (e.g. wearing high heels)
- Activities and habits associated with the condition (sports-related trauma, professional dancers)
- History of wearing orthotics
Observation/Palpation[edit | edit source]
Observation should be completed with the patient in a standing position to determine the direction of weight shift, the presence of smaller toes abnormalities or deviations, or an increase in space between the toes. Next, the clinician should observe while the patient performs a single-leg stance. In addition, the patient may report:
- A history of acute pain in the MTPJs of the smaller toes
- Feeling of local oedema
Tests[edit | edit source]
- A positive anterior-posterior draw test (Modified Lachman Test). The clinician stabilises the patient's toe at the metatarsal and exerts a drawer test on the phalanges. A slight clunk can be heard as the joint subluxes in the plantar direction. It is considered the most reliable and accurate tool to classify and grade a plantar plate lesion. Thompson and Hamilton proposed a classification system based on the level of subluxation of the proximal phalanx:
- G0: stable joint. Pain is present, but no joint deformity.
- G1: mild instability (subluxation < 50%) characterised by widening the space between the toes and medial displacement. Joint pain and swelling.
- G2: moderate instability (subluxation > 50%) with medial, lateral, dorsal or dorsomedial deformity and toe hyperextension. Joint pain with little or no swelling.
- G3: severe instability (capacity for joint dislocation): dorsal or dorsomedial deformity with the second toe overlapping on hallux. A flexible toe clawing may be present. Joint and feet pain, little or no oedema.
- G4: dislocated joint: severe deformity and fixed toe clawing. Joint and feet pain, little or no oedema.
- The negative plantar grip test or "paper-pulling" test: this test is assessed using an 8cm x 1cm strip of paper placed under the 2nd toe of the standing patient. The patient is unable to ‘grip’ the paper.
- A positive Reverse Windlass Test: The patient is standing on the little box with the metatarsals supported at the edge of the box. No pathology: the windlass mechanism plantarflexes the proximal phalanx over the edge of the box. Pathology: lack of toes plantar flexion.
- Manual muscle strength test for the intrinsic muscles and flexor digitorum longus (toe plantar flexion).
Management / Interventions[edit | edit source]
The conservative management of a plantar plate injury should utilise a holistic approach, which addresses shoe wear, local foot support, local and global strength and mobility (foot and lower leg), and a posture assessment.
Shoe wear: no barefoot walking, no high heels, no flexible, minimalist type shoes, like open-toes or flip-flops. Instead, a stiff-soled shoe, a stiff boot or a rocker shoe with a soft insert is recommended.
Local foot support: can include customised orthotics, taping, and toe spacers.
- Customised orthotics usually involve a metatarsal pad
- Toe spacers keep the toes apart
- Taping to offload metatarsal head
- Kinesiotaping method: little fork method
- Cloth adhesive tape: "AIDS" ribbon tape to limit the extension of the second MPTJ
- Local and global strength and mobility: midfoot mobilisation, strengthening of the intrinsics and toe plantar flexors, improving neuromuscular control of the pelvis and hip
Other Interventions[edit | edit source]
- Shock wave therapy
- Cortisone injections - caution: may weaken the plantar plate
- Surgery - however, surgery is complex, and recovery is slow
Resources[edit | edit source]
- Turf toe
- Yamada AF, Crema MD, Nery C, Baumfeld D, Mann TS, Skaf AY, Fernandes ADRC. Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard. AJR Am J Roentgenol. 2017 Aug;209(2):W100-W108.
- Understanding The Biomechanics Of Plantar Plate Injuries
References[edit | edit source]
- Hallinan JTPD, Statum SM, Huang BK, Bezerra HG, Garcia DAL, Bydder GM, Chung CB. High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization. Radiographics. 2020 Jul-Aug;40(4):1107-1124.
- Gyftopoulos S, Woertler K. Ankle and foot. Musculoskeletal Diseases 2021-2024. 2021:107-20.
- Simpson H. Plantar Plate Injuries Course. Plus 2022
- Chen DW, Li B, Aubeeluck A, Yang YF, Huang YG, Zhou JQ, Yu GR. Anatomy and biomechanical properties of the plantar aponeurosis: a cadaveric study. PLoS One. 2014 Jan 2;9(1):e84347.
- Finney FT, McPheters A, Singer NV, Scott JC, Jepsen KJ, Holmes JR, Talusan PG. Microvasculature of the Plantar Plate Using Nano–Computed Tomography. Foot & ankle international. 2019 Apr;40(4):457-64.
- Najefi AA, Jeyaseelan L, Welck M. Turf toe: A clinical update. EFORT Open Rev. 2018 Sep 24;3(9):501-506. doi: 10.1302/2058-5241.3.180012.
- Pelly T, Holme T, Tahir MA, Kunasingam K. Forefoot pain. BMJ. 2020 Oct 9;371.
- Lai SH, Tang CQ, Thevendran G. Forefoot Injuries in Sports. Journal of Foot and Ankle Surgery (Asia Pacific). 2020 Jul;7(2):51.
- Chen X, Zhou G, Xue H, Wang R, Bird S, Sun D, Cui L. High-Resolution Ultrasound of the Forefoot and Common Pathologies. Diagnostics (Basel). 2022 Jun 24;12(7):1541.
- Klein EE, Weil L Jr, Weil LS Sr, Coughlin MJ, Knight J. Clinical examination of plantar plate abnormality: a diagnostic perspective. Foot Ankle Int. 2013 Jun;34(6):800-4.
- Feger J. Medial plantar nerve entrapment. Reference article, Radiopaedia.org. (accessed on 19 Oct 2022)
- Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables. Journal of Surgical Orthopaedic Advances. 2014 Jan 1;23(4):214-23.
- Nery C, Coughlin M, Baumfeld D, Raduan F, Mann TS, Catena F. How to classify plantar plate injuries: parameters from history and physical examination. Rev Bras Ortop. 2015 Oct 26;50(6):720-8.
- Feuerstein CA, Weil L Jr, Weil LS Sr, Klein EE, Fleischer A, Argerakis NG. Static Versus Dynamic Musculoskeletal Ultrasound for Detection of Plantar Plate Pathology. Foot Ankle Spec. 2014 Aug 1;7(4):259-265.
- Albright RH, Brooks B, Chingre M, Klein EE, Weil Jr LS, Fleischer AE. Diagnostic accuracy of magnetic resonance imaging (MRI) versus dynamic ultrasound for plantar plate injuries: A systematic review and meta-analysis. European Journal of Radiology. 2022 Apr 30:110315.
- Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopaedics. 1987 Jan;10(1):83-9.
- Kevin Kirby. Plantarflexion Taping for Plantar Plate Tears. 2016. Available from: https://www.youtube.com/watch?v=meUFV2UQyf8 [last accessed 10/10/2022]
- Ojofeitimi S, Bronner S, Becica L. Conservative management of second metatarsophalangeal joint instability in a professional dancer: a case report. Journal of orthopaedic & sports physical therapy. 2016 Feb;46(2):114-23.
- Labbad ZG, Love E, Shah DN, Kihira Y, Greensberg V. Treatment of lesser metatarsophalangeal joint plantar plate tear via Extracorporeal Pulse Activation Technology (EPAT) with MRI Follow-up: A case report. The Foot and Ankle Online Journal 2020; 13(2): 5. Available from http://faoj.org/2020/07/31/treatment-of-lesser-metatarsophalangeal-joint-plantar-plate-tear-via-extracorporeal-pulse-activation-technology-epat-with-mri-follow-up-a-case-report/ [last access 10.10.2022]